Tang Karen L, Lucyk Kelsey, Quan Hude
Affiliations: Departments of Medicine (Tang) and Community Health Sciences (Lucyk, Quan), University of Calgary, Calgary, Alta.
CMAJ Open. 2017 Aug 15;5(3):E617-E622. doi: 10.9778/cmajo.20170036.
Professional coding specialists ("coders") are experts at translating patient chart information into alphanumerical codes, which are then widely used in research and health policy decision-making. Coders rely solely on documentation by health care providers to complete this task. We aimed to explore physician-related barriers to coding that results in high-quality administrative data.
In a qualitative study conducted from December 2015 to March 2016, we recruited 28 coders who worked in health care facilities in Alberta using purposive and snowball sampling. Semistructured interviews were conducted, audio-recorded and transcribed. The interviews delved into coder training, work environment, documentation and coding standards. Thematic content analysis of transcripts was performed by 2 study investigators through line-by-line coding and constant comparison, after which the codes were collated into themes.
Five themes emerged regarding physician-related barriers in coding of high-quality administrative data: 1) coders are limited in their ability to add to, modify or interpret physician documentation, which supersedes all other chart documentation, 2) physician documentation is incomplete and nonspecific, 3) chart information tends to be replete with errors and discrepancies, 4) physicians and coders use different terminology to describe clinical diagnoses and 5) there is a communication divide between coders and physicians, such that questions and issues regarding physician documentation cannot be reconciled.
Physicians play a major role in influencing the quality of administrative data. There is a need for physicians to advocate for culture change in physicians' attitudes toward coders and chart documentation, in recognition of the importance of accurate chart information.
专业编码专家（“编码员”）擅长将患者病历信息转化为字母数字代码，这些代码随后广泛应用于研究和卫生政策决策。编码员完全依赖医疗服务提供者的文档来完成这项任务。我们旨在探究与医生相关的编码障碍，这些障碍会影响高质量管理数据的生成。
在2015年12月至2016年3月进行的一项定性研究中，我们采用目的抽样和滚雪球抽样的方法，招募了28名在艾伯塔省医疗机构工作的编码员。进行了半结构化访谈，并进行了录音和转录。访谈深入探讨了编码员培训、工作环境、文档和编码标准。两名研究调查员通过逐行编码和持续比较对转录本进行主题内容分析，之后将代码整理成主题。
在高质量管理数据编码中出现了五个与医生相关的障碍主题：1）编码员在补充、修改或解释医生文档方面的能力有限，医生文档优先于所有其他病历文档；2）医生文档不完整且不具体；3）病历信息往往充满错误和差异；4）医生和编码员使用不同术语描述临床诊断；5）编码员和医生之间存在沟通鸿沟，导致关于医生文档的问题无法得到解决。
医生在影响管理数据质量方面起着主要作用。医生需要倡导改变对编码员和病历文档的态度，认识到准确病历信息的重要性。
